Assessment of Postvaccination Neutralizing Antibodies Response against SARS-CoV-2 in Cancer Patients under Treatment with Targeted Agents.

The administration of a third dose of a vaccine against SARS-CoV-2 has increased protection against disease transmission and severity. However, the kinetics of neutralizing antibodies against the virus has been poorly studied in cancer patients under targeted therapies. Baseline characteristics and levels of neutralizing antibodies at specific timepoints after vaccination were compared between patients suffering from breast, ovarian or prostate cancer and healthy individuals. Breast cancer patients were treated with cyclin D kinase 4/6 inhibitors and hormonal therapy, ovarian cancer patients were treated with poly (ADP-ribose) polymerase inhibitors and prostate cancer patients were treated with an androgen receptor targeted agent. Levels of neutralizing antibodies were significantly lower in cancer patients compared to healthy individuals at all timepoints. Antibodies' titers declined over time in both groups but remained above protective levels (>50%) at 6 months after the administration of the second dose. The administration of a third dose increased neutralizing antibodies' levels in both groups. The titers of protective against SARS-CoV-2 antibodies wane over time and increase after a third dose in cancer patients under treatment.

Assessment of frailty and related outcomes in older patients with heart failure: A cohort study.

OBJECTIVE: Heart failure (HF) is a common cause of morbidity and mortality in older patients. Frailty is prevalent and complicates the course of HF. We sought to investigate the impact of frailty on HF outcomes. METHODS: Patients over 65 years old hospitalized with acute decompensated HF and mildly reduced or preserved EF, between September 2017 and September 2019 were enrolled in the study. Before hospital discharge at euvolemic state, patients underwent six-minute walk test (6MWT) and frailty assessment using FRIED and modified SOF scores. Predictors of death, readmissions, and increase in diuretic dose were analyzed by multivariable logistic regression models. RESULTS: We enrolled 193 consecutive patients (mean age 78.6 ± 8.4 years, 29.5% males, 59.6% with HF and preserved EF). All patients had at least one comorbidity (40.9% coronary artery disease, 71% diabetes, and 86% hypertension). The mean 6MWT distance was 316.2 meters. According to FRIED score, 4.7% were normal and 17.6% were categorized as pre-frail and 77.7% as frail, while according to SOF index 9.8% were normal, 15% were categorized as pre-frail and 75.1% as frail. Frail patients according to both indices had a higher risk of 90-day readmissions, uptitration of diuretics within 90 days (p < 0.001 for both) and numerically but not significantly higher risk of death. Frailty status was independently associated with higher risk of 90-day readmissions, uptitration of diuretics, and higher BNP at 90 days. CONCLUSIONS: Frailty in older patients with HF is common and associated with worse prognosis. Pre-discharge frailty assessment may aid in identification of patients at high-risk for short-term complications.

Transcatheter Versus Surgical Aortic Valve Replacement in the United States (From the Nationwide Readmission Database).

Clinical outcomes of transcatheter aortic valve implantation (TAVI) have significantly improved with the accumulation of operator and institution experience as well as the wide use of newer generation devices. There is limited data on TAVI outcomes compared with surgical aortic valve replacement (SAVR) in contemporary practice in the United States. We queried the 2018 Nationwide Readmission Database of the United States. International Classification Diagnosis code 10 was used to extract TAVI and SAVR admissions. A propensity-matched cohort was created to compare TAVI and SAVR outcomes. A weighted 48,349 TAVI and 24,896 SAVR for aortic stenosis were included and 4.9% of TAVI were performed with an embolic protection device. In propensity-matched cohort (12,708 TAVI and 12,708 SAVR), TAVI conferred lower in-hospital mortality (1.7% vs 3.8%), acute kidney injury (11.3% vs 22.9%), and transfusion rate (5.9% vs. 20.6%) whereas new pacemaker rate was higher in TAVI compared with SAVR (10.5% vs. 7.0%) (all p values < 0.001). Stroke rate was similar between TAVI and SAVR (1.5% vs. 1.5%) (p value = 0.79). The routine discharge was more frequent (66.9% vs 25.8%) and length of stay was shorter (4.8 vs. 9.8 days) in TAVI than SAVR. Hospitalization cost was higher in SAVR than TAVI (51,962 vs 57,754 U.S. dollars) (all p values < 0.001). In-hospital mortality was also lower in TAVI compared with isolated SAVR. TAVI was performed more frequently than SAVR in 2018 in the United States with lower in-hospital mortality of TAVI compared with both SAVR and isolated SAVR.

Characteristics, trends, outcomes, and costs of stimulant-related acute heart failure hospitalizations in the United States.

BACKGROUND: Heart failure (HF) hospitalizations remains a significant burden on the health care system. Stimulants including cocaine, amphetamine and its derivatives are amongst the most used illegal substances in the United States. The information regarding stimulant-related HF hospitalizations is scarce. We sought to evaluate the characteristics and trends of stimulant-related HF hospitalizations in the United States and their associated outcomes and resource utilization. METHODS: Using the National Inpatient Sample (NIS), we identified patients with a primary diagnosis of HF hospitalization. These hospitalizations were further divided into those with and without a concomitant diagnosis of stimulant (cocaine or amphetamine) dependence or abuse. Survey specific techniques were employed to compare trends in baseline characteristics, complications, procedures, outcomes and resource utilization between the two cohorts. RESULTS: We identified 9,932,753 hospitalizations (weighted) with a primary diagnosis of heart failure, of those 138,438 (1.39%) had a diagnosis of active stimulant use. The proportion of stimulant-related HF hospitalization is on the rise (1.1% to 1.9%). Stimulant-related HF hospitalization was highest amongst age group 30-39 years and 7.9% of HF hospitalizations in this age group were due to stimulant use. The proportion of stimulant-related HF hospitalization for the White and Hispanic race has doubled from 2008 to 2017. Stimulant-related HF hospitalization is associated with increased incidence of in-hospital complications like cardiogenic shock, acute kidney injury and ventricular tachycardia. These patients have more than 7-fold higher discharge against medical advice. CONCLUSIONS: Stimulant-related HF hospitalizations have been increasing. It is associate with significant morbidity burden and health care utilization.

Trends, Perioperative Adverse Events, and Survival of Patients With Left Ventricular Assist Devices Undergoing Noncardiac Surgery.

Importance: Information regarding the performance and outcomes of noncardiac surgery (NCS) in patients with left ventricular assist devices (LVADs) is scarce, with limited longitudinal follow-up data that are mostly limited to single-center reports. Objective: To examine the trends, patient characteristics, and outcomes associated with NCS among patients with LVAD. Design, Setting, and Participants: This cohort study examined patients enrolled in Medicare undergoing durable LVAD implantation from January 2012 to November 2017 with follow-up through December 2017. The study included all Medicare Provider and Analysis Review Part A files for the years 2012 to 2017. Patients identified by International Classification of Diseases, Ninth Revision Clinical Modification (ICD-9-CM) and International Classification of Diseases, Tenth Revision (ICD-10) procedure codes for new LVAD implantation were included. Data analysis was performed from November 2019 to February 2020. Exposures: NCS procedures were identified using the ICD-9-CM and ICD-10 procedural codes and divided into elective and urgent or emergent. Main Outcomes and Measures: The primary outcome was major adverse cardiovascular events (MACEs), defined as in-hospital or 30-day all-cause mortality, ischemic stroke, or intracerebral hemorrhage after NCS. Early (<60 days after NCS) and late (≥60 days after NCS) mortality after NCS were analyzed in both subgroups using time-varying covariate and landmark analysis using patients who did not undergo NCS as reference. Results: Of the 8118 patients with LVAD (mean [SD] age, 63.4 [10.8] years; 6484 men [79.9%]), 1326 (16.3%, or approximately 1 in 6) underwent NCS, of which 1000 procedures (75.4%) were emergent or urgent and 326 (24.6%) were elective. There was no difference in age between patients who underwent NCS and patients who did not (mean [SD] age, 63.6 [10.6] vs 63.4 [10.9] years). The number of NCS procedures among patients with LVAD increased from 64 in 2012 to 304 in 2017. The median (interquartile range) time from LVAD implantation to NCS was 309 (133-606) days. The most frequent type of NCS was general (613 abdominal, pelvic, and gastrointestinal procedures [46.2%]). Perioperative MACEs occurred in 169 patients (16.9%) undergoing emergent or urgent NCS and 23 patients (7.1%) undergoing elective NCS. Urgent or emergent NCS was associated with higher mortality early (adjusted hazard ratio [aHR], 8.78; 95% CI, 7.20-10.72; P < .001) and late (aHR, 1.71; 95% CI, 1.53-1.90; P < .001) after NCS compared with patients with LVAD who did not undergo NCS. Elective NCS was also associated with higher mortality early (aHR, 2.65; 95% CI, 1.74-4.03; P < .001) and late (aHR, 1.29; 95% CI, 1.07-1.56; P = .008) after NCS. Conclusions and Relevance: One of 6 patients with LVAD underwent NCS. Perioperative MACEs were frequent. Higher mortality risk transcended the early postoperative period in urgent or emergent and elective surgical procedures.

Racial disparities in in-hospital outcomes after left ventricular assist device implantation.

BACKGROUND: Previous studies of patients undergoing various cardiac surgeries demonstrated worse outcomes among African-American (AA) patients. It remains unclear if the race is a predictor of outcomes among left ventricular assist device (LVAD) recipients. METHODS: Patients who underwent LVAD implantation between 2010 and 2017 were identified using the National Inpatient Sample. The race was classified as Caucasians vs AA vs Hispanics, and endpoints were in-hospital outcomes, length of stay, and cost. Procedure-related complications were identified via the International Classification of Diseases-9 (ICD-9) and ICD-10 coding and analysis performed via mixed-effect models. RESULTS: A total of 27 132 adults (5114 unweighted) underwent LVAD implantation in the U.S. between 2010 and 2017, including Caucasians (63.8%), AA (23.8%), and Hispanics (6%). The number of LVAD implantations increased in both Caucasians and AA during the study period. AA LVAD recipients were younger, with higher rates of females and mostly comorbidities, but lower rates of coronary artery disease and bypass grafting compared to Caucasians and Hispanics. Medicaid and median income at the lowest quartile were more frequent among AA LVAD recipients. We did not identify differences in stroke, bleeding complications, tamponade, infectious complications, acute kidney injury requiring hemodialysis, and in-hospital mortality among racial groups. AA LVAD recipients had lower rates of routine discharge than Caucasians and Hispanics, longer length of stay than Caucasians, but similar cost of hospitalization. After adjustment for clinical comorbidities, race was not a predictor of in-hospital mortality. CONCLUSION: We identified differences in clinical characteristics but not in in-hospital complications among LVAD recipients of a different races.

Potentially harmful drug prescription in elderly patients with heart failure with reduced ejection fraction.

AIMS: This study aimed to evaluate the prescription frequency of potentially harmful prescription drugs as defined in current heart failure guidelines among elderly patients with a diagnosis of heart failure with reduced ejection fraction and their association with clinical outcomes. METHODS AND RESULTS: We used the Centers for Medicare & Medicaid Services data from a nationally representative 5% sample for the years 2014-2016 to identify patients admitted to acute care hospitals with a primary diagnosis of heart failure with reduced ejection fraction. The primary exposure was filling a prescription for a potentially harmful drug. Potentially harmful drug fills were treated as a time-dependent covariate to examine their association on readmission and mortality. A total of 8993 patients met study criteria. Potentially harmful drugs were prescribed in 1077 (11.9%) patients within 90 days of discharge from the heart failure hospitalization. Non-steroidal anti-inflammatory agents were the most frequently prescribed potentially harmful drug (6.7%) followed by calcium channel blockers (4.7%), thiazolidinedione (0.59%), and select antiarrhythmic (0.33%). Factors independently associated with potentially harmful drug prescription were female gender, Hispanic ethnicity, severe obesity, among others. In the multivariable Cox model, the prescription of a potentially harmful drug was associated with an increased risk of readmission (hazard ratio 1.14; 95% confidence interval 1.05-1.23, P < 0.001). Among drug subgroups, only calcium channel blockers were associated with an increased risk of readmission (hazard ratio 1.225; 95% confidence interval 1.085-1.382, P = 0.0011). CONCLUSIONS: In elderly patients discharged with a primary diagnosis of heart failure with reduced ejection fraction on guideline-directed medical therapy, prescription of a potentially harmful drug was frequent. Calcium channel blockers were associated with an increased risk of readmission.

Outcomes of Thoracentesis for Acute Heart Failure in Hospitals.

Data on in-hospital outcomes for hospitalizations undergoing thoracentesis (THR) for any cause has been conflicting. For hospitalizations with acute heart failure (HF), however, to date, no study has evaluated the outcomes of THR. Accordingly, our current study addresses this knowledge gap. We analyzed data from the Nationwide Inpatient Sample (2005-14). The study population included all adults (>18 years) with the principal discharge diagnosis of HF and the presence of procedure code for THR. Hospitalizations with pneumonia, acute kidney injury, and co-morbidities such as malignancy, lymphoma, liver disease, end-stage renal disease, metastatic disease, and tuberculosis were excluded. Propensity matching was performed to identify a similar cohort of admissions that did not undergo THR. Primary outcome of interest was in-hospital mortality and length of hospitalization. During the study period, 2,251,927 hospitalizations for HF were found from the database; of which, 70,823 (3.14%) had THR. After propensity matching, a matched cohort of 70,785 hospitalizations for HF was identified. In-hospital mortality was higher for those who underwent THR (2.5% vs 1.6%; p <0.001). In-hospital complications and procedures including cardiac arrest, sepsis, pneumothorax and hemothorax were more frequent in the THR group. Those who underwent THR had a longer mean length of stay (6.9 vs 4.5 days; p <0.01) and higher cost of hospitalization ($13,448 vs $ 8940; p <0.01). The trend analysis demonstrated a steady increase in the performance of THR in hospitalized HF between 2005 and 2014. In conclusion, THR performed during HF hospitalizations were associated with higher rates of in-hospital mortality, complications and increased healthcare utilization in the form of longer length of stay and higher costs.

The impact of insurance type on listing status and wait-list mortality of patients with left ventricular assist devices as bridge to transplantation.

AIMS: Adequate health insurance coverage is necessary for heart transplantation (HT) candidates. Prior studies have suggested inferior outcomes post HT with public health insurance. We sought to evaluate the effects of insurance type on transplantation rates, listing status and mortality prior to HT. METHODS AND RESULTS: Patients ≥18 years old with a left ventricular assist device implanted and listed with 1A status were identified in the United Network for Organ Sharing registry between January 2010 and December 2017, with follow-up through March 2018. Patients were grouped based on the type of insurance private/self-pay (PV), Medicare (MC), and Medicaid (MA) at the time of listing. We conducted multivariable competing risks regression analysis on listing status and mortality on the waiting list, stratified by insurance type at the time of listing. We identified 2604 patients listed in status 1A (PV: 51.4%, MC: 32.1%, and MA: 16.5%). MA patients were younger (43.5 vs. 56.4 for MC vs. 51.5 for PV, P < 0.001) and less frequently White (P < 0.001). The cumulative incidence of HT did not differ among the three insurance types (PV: 74.8%, MC 76.3%, and MA 71.1%, P = 0.14). The cumulative mortality on the waiting list prior to HT was not different among groups (PV: 29.3%, MC 26.3%, and MA 21.8%, P = 0.94). Μore patients with MA were removed from the list because of improvement of their condition (MA 40.3% vs. MC 28.3% and PV 32.8%). CONCLUSIONS: We did not detect any disparities in listing status and mortality among different insurance types.

Characteristics and outcomes in patients with atrial fibrillation receiving direct oral anticoagulants in off-label doses.

BACKGROUND: We evaluated adherence to dosing criteria for patients with atrial fibrillation (AF) taking dabigatran or rivaroxaban and the impact of off-label dosing on thromboembolic and bleeding risk. METHODS: We used data for a retrospective cohort from a large U.S. health plan for Medicare beneficiaries age > =65 years with AF who initiated dabigatran or rivaroxaban during 2010-2016. Stroke and major bleeding were quantified in patients who were eligible for low dose but received standard dose, and in patients who were eligible for standard dose but received low dose. RESULTS: We identified 8035 and 19,712 patients who initiated dabigatran or rivaroxaban, respectively. Overall, 1401 (17.4%) and 7820 (39.7%) patients who received dabigatran and rivaroxaban met criteria for low dose, respectively. Of those, 959 (68.5%) and 3904 (49.9%) received standard dose. In contrast, 1013 (15.3%) and 2551 (21.5%) of patients eligible for standard dose dabigatran and rivaroxaban received low dose. Mean follow-up for patients eligible for low and standard dose dabigatran and rivaroxaban were 13.9, 15.1, 10.1, and 12.3 months, respectively. In unadjusted analyses, patients eligible for low or standard dose dabigatran and rivaroxaban but receiving off-label dose, had no differences in the rates of ischemic stroke. Among patients who met criteria for standard dose direct oral anticoagulants (DOAC), use of low dose was associated with significantly higher risk of any major bleeding (Dabigatran: HR = 1.44; 95% CI 1.14-1.8, P = 0.002, Rivaroxaban HR 1.34, 95% CI 1.11-1.6, P = 0.002) and gastrointestinal bleeding (Dabigatran: HR = 1.48; 95% CI 1.08-2, P = 0.016). In patients who met criteria for low dose DOACs, there was lower risk of major bleeding (Dabigatran: HR = 0.59; 95% CI 0.43-0.8, P < 0.001), gastrointestinal (Rivaroxaban: HR 0.79; 95% CI 0.64-0.98, P = 0.03) and intracranial bleeding (Dabigatran: HR = 0.33; 95% CI 0.12-0.9, P = 0.001) with standard dosing. After propensity matching, use of off-label doses was not associated with stroke, major, gastrointestinal or intracranial bleeding for either dabigatran or rivaroxaban. CONCLUSIONS: While a significant number of patients receive higher or lower dose of dabigatran and rivaroxaban than recommended, we found no evidence of significant impact on thromboembolic or hemorrhagic outcomes.

Trends in utilization, mortality, major complications, and cost after total artificial heart implantation in the United States (2009-2015).

OBJECTIVE: Total artificial heart (TAH) is a viable bridge to transplant (BTT) strategy for patients with severe biventricular failure or complex congenital heart disease. These patients have higher mortality and morbidity than patients undergoing left ventricular assist device (LVAD) implantation. To assess national trends in in-hospital mortality, major complications, cost, length of stay, and disposition of patients undergoing TAH implantation. METHODS: Data from the National Inpatient Sample, the largest all-payer inpatient data set in the United States, and the US Census Bureau, for the years 2009 to 2015 were analyzed. Participants included all adult patients who received TAH from 2009 to 2015. Endpoints included in-hospital mortality, in-hospital complications, heart transplantation (HT) in the same admission, length of stay, cost, and disposition at the time of discharge. RESULTS: We identified a total of 143 (weighted = 703) TAH implantations. The number of TAH implants increased during the study period (average annual change +5.8%, p = 0.03). Rates of in-hospital mortality and major complications including ischemic stroke, major bleeding, postoperative infections, acute kidney injury requiring dialysis, and HT did not change significantly over the study period. Although the length of stay and disposition patterns did not change over time, we found a significant increase in cost of hospitalization (average annual change +44,362, p = 0.01). The number of HT during the same hospital stay decreased significantly (average annual change -8.1%, p = 0.02). CONCLUSION: In-hospital mortality and complication rates associated with TAH implantation remain increased and did not change in the era of continuous flow LVADs.

Early Invasive Versus Ischemia-Guided Strategy in Non-ST-Segment Elevation Acute Coronary Syndrome With Chronic Obstructive Pulmonary Disease: A National Inpatient Sample Analysis.

Chronic obstructive pulmonary disease (COPD) is a risk factor for non-ST-segment elevation-acute coronary syndromes (NSTE-ACS). Whether early invasive strategy (EIS) or ischemia-guided strategy (IGS) confers better outcomes in NSTE-ACS with COPD is largely unknown. Nationwide Inpatient Sample database of the United States was queried from 2010 to 2015 to identify NSTE-ACS with and without COPD. Early invasive strategy was defined as coronary angiogram with or without revascularization on admission day 0 or 1, whereas IGS included patients who did not receive EIS. Standardized morbidity ratio weight was used to calculate the adjusted odds ratio. A total of 228 175 NSTE-ACS admissions with COPD were identified of which 34.0% received EIS. In-hospital mortality was lower with EIS in patients with COPD (3.1% vs 5.5%, adjusted odds ratio 0.57, 95% confidence interval 0.50-0.63) compared to IGS, but the magnitude of mortality reduction observed in EIS in patients with COPD was less compared to non-COPD patients (P interaction = .02). Length of stay was shorter (4.2 vs 4.7 days, P < .0001) but the cost was higher (US$23 804 vs US$18 533, P < .0001) in EIS in COPD. Early invasive strategy resulted in lower in-hospital mortality and marginally shorter length of stay but higher hospitalization cost in NSTE-ACS with COPD.

Impact of Pre-Existing and New-Onset Atrial Fibrillation on Outcomes After Transcatheter Aortic Valve Replacement.

OBJECTIVES: This study sought to evaluate impact of new-onset and pre-existing atrial fibrillation (AF) on transcatheter aortic valve replacement (TAVR) long-term outcomes compared with patients without AF. BACKGROUND: Pre-existing and new-onset AF in patients undergoing TAVR are associated with poor outcomes. METHODS: The study identified 72,660 patients ≥65 years of age who underwent nonapical TAVR between 2014 and 2016 using Medicare inpatient claims. History of AF was defined by diagnoses on claims during the 3 years preceding the TAVR, and new-onset AF was defined as occurrence of AF during the TAVR admission or within 30 days after TAVR in a patient without prior history of AF. Outcomes included all-cause mortality, and readmission for bleeding, stroke, and heart failure (HF). RESULTS: Overall, 40.7% had pre-existing AF (n = 29,563) and 6.8% experienced new-onset AF (n = 2,948) after TAVR. Mean age was 81.3, 82.4, and 83.8 years in patients with no AF, pre-existing, and new-onset AF, respectively. Pre-existing AF patients had the highest burden of comorbidities. After follow-up of 73,732 person-years, mortality was higher with new-onset AF compared with pre-existing and no AF (29.7, 22.6, and 12.8 per 100 person-years, respectively; p < 0.001). After adjusting for patient characteristics and hospital TAVR volume, new-onset AF remained associated with higher mortality compared with no AF (adjusted hazard ratio: 2.068, 95% confidence interval [CI]: 1.92 to 2.20; p < 0.01) and pre-existing AF (adjusted hazard ratio: 1.35; 95% CI: 1.26 to 1.45; p < 0.01). In competing risk analysis, new-onset AF was associated with higher risk of bleeding (subdistribution hazard ratio [sHR]: 1.66; 95% CI: 1.48 to 1.86; p < 0.01), stroke (sHR: 1.92; 95% CI: 1.63 to 2.26; p < 0.01), and HF (sHR: 1.98; 95% CI: 1.81 to 2.16; p < 0.01) compared with pre-existing AF. CONCLUSIONS: In patients undergoing TAVR, new-onset AF is associated with increased risk of mortality and bleeding, stroke, and HF hospitalizations compared with pre-existing AF or no AF.

Trends in In-Hospital Mortality, Length of Stay, Nonroutine Discharge, and Cost Among End-Stage Renal Disease Patients on Dialysis Hospitalized With Heart Failure (2001-2014).

BACKGROUND: Heart failure (HF) is a common cause of morbidity and mortality among end-stage renal disease (ESRD) patients on dialysis. We aimed to assess the trends and outcomes in primary and secondary HF hospitalizations among ESRD patients with the use of a nationally representative database. METHODS AND RESULTS: We analyzed data from the National Inpatient Sample and the US Census Bureau to calculate annual national rates of in-hospital mortality, length of stay, disposition with a focus on nonroutine discharge (discharge to a health care facility rather than to home), and adjusted median cost among patients with ESRD on dialysis with primary or secondary HF admissions from 2001 to 2014. An estimated 812,090 primary and 2,887,432 secondary HF admissions occurred from 2001 to 2014. The prevalence of comorbidities increased during the study period. Primary HF admission rates increased from 2001 to 2006 and decreased from 2007 to 2014, whereas secondary HF admissions increased significantly during the study period (P < .001). We found statistically significant declines of primary and secondary admission in-hospital mortality, with annual percentage changes of -3.1% and -2.6% respectively (P < .001 for both). In addition, the lengths of stay decreased significantly for primary and secondary HF admissions (P < .001 for both). However, nonroutine discharges increased significantly for both. Subgroup analysis showed higher in-hospital mortality for men, patients >65 years of age, whites, and those on peritoneal dialysis. The cost of hospitalization did not change significantly for primary and secondary HF admissions. CONCLUSION: Among ESRD patients on dialysis with primary or secondary HF admission diagnosis, comorbidity prevalence increased but in-hospital mortality and length of stay decreased significantly from 2001 to 2014.

Predictors of Hospital Cost After Transcatheter Aortic Valve Implantation in the United States: From the Nationwide Inpatient Sample Database.

We aimed to identify risk factors of high hospitalization cost after transcatheter aortic valve implantation (TAVI). TAVI expenditure is generally higher compared with surgical aortic valve replacement. We queried the Nationwide Inpatient Sample database from January 2011 to September 2015 to identify those who underwent endovascular TAVI. Estimated cost of hospitalization was calculated by merging the Nationwide Inpatient Sample database with cost-to-charge ratios available from the Healthcare Cost and Utilization Project. Patients were divided into quartiles (lowest, medium, high, and highest) according to the hospitalization cost, and multivariable regression analysis was performed to identify patient characteristics and periprocedural complications associated with the highest cost group. A total of 9,601 TAVI hospitalizations were identified. Median in-hospital costs of the highest and lowest groups were $82,068 and $33,966, respectively. Patients in the highest cost group were older and more likely women compared with the lowest cost group. Complication rates (68.4% vs 22.5%) and length of stay (median 10 days vs 3 days) were both approximately 3 times higher and longer, respectively, in the highest cost group. Co-morbidities such as heart failure, peripheral vascular disease, atrial fibrillation, anemia, and chronic dialysis as well as almost all complications were associated with the highest cost group. The complications with the highest incremental cost were acute respiratory failure requiring intubation ($28,209), cardiogenic shock ($22,401), and acute kidney injury ($16,974). Higher co-morbidity burden and major complications post-TAVI were associated with higher hospitalization costs. Prevention of these complications may reduce TAVI-related costs.

Incidence, Predictors, and In-Hospital Outcomes of Transcatheter Aortic Valve Implantation After Nonelective Admission in Comparison With Elective Admission: From the Nationwide Inpatient Sample Database.

Candidates for transcatheter aortic valve implantation (TAVI) are generally older with multiple co-morbidities and are therefore susceptible to nonelective admissions before scheduled TAVI. Frequency, predictors, and outcomes of TAVI after nonelective admission are under-explored. We queried the Nationwide Inpatient Sample database, an administrative database, from January 2012 to September 2015 to identify hospitalization in those age ≥50 who had transarterial TAVI. A propensity-matched cohort was created to compare the outcomes between nonelective and elective admission who had TAVI. The primary outcome was in-hospital mortality. A total of 9,521 TAVI admissions were identified during the study period. Of these admissions, 22.3% were nonelective admissions. Pulmonary circulation disorders (adjusted odds ratio [aOR] 1.38), anemia (aOR 1.54), congestive heart failure (aOR 1.37), chronic kidney disease (aOR 1.28; all p <0.001), and atrial fibrillation (aOR 1.17, p = 0.006) were independent risk factors for nonelective admission. In a propensity-matched cohort (1,683 admissions in each cohort), in-hospital mortality was similar (4.0% vs 2.8%, p = 0.052). Nonelective admissions had higher rates of acute myocardial infarction (5.2% vs 0.7%), fatal arrhythmia (9.4% vs 6.0%), acute kidney injury (25.9% vs 17.1%), respiratory failure requiring intubation (0.26% vs 0.19%), cardiogenic shock (5.1% vs 2.1%; all p <0.001), and bleeding requiring transfusion (13.1% vs 10.1%, p = 0.006) during the index-hospitalization. Hospital length of stay (11.4 days vs 6.5 days, p <0.001) and hospital cost ($68,669 vs $57,442, p <0.001) were both increased in nonelective admissions. Nonelective admission accounted for approximately one-fifth of total TAVI with significantly different cohort profiles. Our results suggest that nonelective TAVI has higher adverse outcomes and increased health resource utilization. Expedition in TAVI process in high-risk cohorts may result in better outcomes.

Effect of Hospital Ownership on Outcomes After Left Ventricular Assist Device Implantation in the United States.

BACKGROUND: We evaluated the effects of hospital ownership, classified into three tiers (nonfederal government, not-for-profit, and for-profit hospitals), on in-hospital outcomes after implantation of continuous-flow left ventricular assist devices (LVADs) in the United States from 2009 to 2014. METHODS: Data from the National Inpatient Sample were used to calculate annual national estimates in utilization, in-hospital mortality, major complications, lengths of stay, cost of hospitalization, and disposition at discharge for years 2009 to 2014. Complications were calculated using patient safety indicators and International Classification of Diseases, Ninth Revision, Clinical Modification codes. RESULTS: Of the 3,571 patients (weighted, 17,547) with LVAD implants in the United States between 2009 and 2014, 82.1% were in not-for-profit hospitals, 15.6% in nonfederal government hospitals, and 2.3% in for-profit hospitals. In-hospital mortality significantly decreased over time only in not-for-profit hospitals by average annual change of -7.4% (p = 0.001) and was higher in for-profit hospitals than other tiers of hospital ownership. Our analysis did not suggest any differences in postoperative complications among different hospital ownership types. LVAD implantation in nonfederal government hospitals was associated with the highest cost ($227,930; interquartile range [IQR], $173,259 to $301,566) and implantation in for-profit hospitals was associated with lower cost ($148,406; IQR, $133,149 to $199,317; p = 0.03). The length of stay was similar across the three tiers of hospital ownership. Nonroutine discharge was significantly more frequent in not-for-profit hospitals (73.6%; IQR 69.5% to 77.7%) compared with nonfederal government (48.8%; IQR, 42.4% to 55.1%) and for-profit (59.8%; IQR, 43.0% to 76.6%) hospitals (p < 0.001). CONCLUSIONS: Disparities in in-hospital mortality, cost, and disposition exist between various hospital ownerships during admission for LVAD implant.

Acute Myocardial Infarction Outcomes in Systemic Lupus Erythematosus (from the Nationwide Inpatient Sample).

One of the major causes of mortality in systemic lupus erythematosus (SLE) is acute myocardial infarction. Whether in-hospital outcomes and management of ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) are different in SLE patients compared with those without SLE from large, recent dataset is unclear. We queried the Nationwide Inpatient Database from 2005 to 2014 and identified STEMI and NSTEMI admissions with and without SLE. The primary outcome was in-hospital mortality. Secondary outcomes were revascularization strategy (percutaneous coronary intervention, coronary artery bypass surgery, or thrombolytics), medical therapy rates (no reperfusion), and major adverse clinical events. A propensity-matched cohort was created to compare these outcomes. Odds ratio (OR) was calculated from the propensity-matched cohort. A total of 321,048 STEMI admissions, of which 1,001 (0.31%) and 572,971 NSTEMI admissions, of which 2,134 (0.37%) were SLE, were identified. In those with STEMI, 882 SLE and non-SLE admissions were propensity-matched. In-hospital mortality (9.1% vs 11.8%, OR 0.75, p = 0.07), revascularization strategy, medical therapy rates, and major adverse events were similar. Similarly, in those with NSTEMI, 1,770 SLE and 1,775 non-SLE were matched. In-hospital mortality (4.1% vs 4.50%, OR 0.90, p = 0.51), coronary artery bypass surgery, medical therapy rates, and major adverse events were mostly similar but the rate of percutaneous coronary intervention was higher in SLE (32.9% vs 29.6%, OR 1.16, p = 0.04). For both STEMI and NSTEMI, hospital cost and length of stay were similar between SLE and non-SLE cohorts. From a large administrative database in the United States, revascularization strategies and in-hospital outcomes of acute coronary syndrome were mostly similar between SLE and non-SLE.

Predictors, Burden, and the Impact of Arrhythmia on Patients Admitted for Acute Myocarditis.

A significant proportion of patients with acute myocarditis experience sudden cardiac death presumably due to cardiac arrhythmia. In this study, we explore the burden, the predictors of arrhythmia in acute myocarditis and the association between arrhythmias and adverse in-hospital outcomes. After evaluating the frequency of various tachyarrhythmias and bradyarrhythmia in myocarditis population, we built a logistic model to determine the independent predictors of arrhythmias in myocarditis and a 1:1 propensity-matched analysis to examine the impact of arrhythmias. Overall, cardiac arrhythmias were identified in 33.71% of the hospitalized myocarditis cases. Ventricular tachycardia and atrial fibrillation were most common arrhythmias. There were increased odds of in-hospital mortality, cardiogenic shock, use of mechanical circulatory support, pacemaker implantation, and nonroutine hospital discharges in the arrhythmia cohorts. Length of stay and cost of hospitalization were also significantly higher. A significant proportion of patients with myocarditis have cardiac arrhythmias. As the occurrence of arrhythmias in myocarditis is associated with worse outcomes, it may be important to risk stratify patient to identify those who will benefit from early intervention.